TB-Tuberculosis is a serious communicable disease. It can affect different parts of the body. It can be pulmonary and extra pulmonary. Pulmonary TB, or TB in the lung, can be spread from person to person through droplets in the air. Extra pulmonary can affect intestine, bone, lymph node etc. In ENT practice, TB of Larynx, Lymph Node, Tonsil, Nose and Nasopharynx and Ear are rare but do occur.
Primary tuberculosis of the ear has rarely been reported. Tuberculosis of the middle ear is characterized by painless otorrhoea, multiple tympanic perforations, abundant granulation tissue, bone necrosis and severe hearing loss. Tuberculous otitis media should always be considered in differential diagnosis of chronic middle ear discharge that does not respond to usual treatment.
Otogenic complication as facial palsy and sensorineural hearing loss were more frequent in tuberculous otitis patients, than in cholesteatoma. Also, fistulas of the labyrinth and facial canal bone destruction were also more frequent in tuberculous otitis than in cholesteatoma. A larger extent of temporal bone destruction was noticed on CT scans of the temporal bone in half of the patents with tuberculous otitis. Coexistence with miliary pulmonary tuberculosis was detected in one third of the patients.
Histopathological features of TOM are not a typically formed granuloma. PPD testing is not a reliable diagnostic procedure.
Symptoms
Generally tuberculosis of middle ear is unilateral. Tuberculosis of middle ear is characterized by painless otorrhoea which fails to respond to the usual antimicrobial treatment, in a patient with evidence of tubercle infection elsewhere followed by multiple tympanic membrane perforations, abundant granulation tissue, and bone necrosis, preauricular lymphadenopathy. There may be multiple perforations in the early stages, but they coalesce into a total tympanic membrane perforation accompanied by a pale granulation tissue. Preauricular fistulas, lymphadenopathy, and facial palsy are infrequent findings. Late complications include facial paralysis, labyrinthitis, postauricular fistulae, subperiosteal abscess, petrous apicitis, and intracranial extension of infection.
Differential diagnosis
The differential diagnosis of tuberculous otitis media includes fungal infections, Wegener’s granulomatosis, midline granuloma, sarcoidosis, syphilis, necrotizing otitis externa, atypical mycobacterial infections, lymphoma, histiocytosis X and cholesteatoma .These diagnoses can be ruled out clinically by the presence of pain and the type and consistency of the discharge. In diagnosing tuberclulous otitis media, it is important to consider it as a differential diagnosis of chronic suppurative otitis media. The diagnosis of tuberculous otitis media is often missed in the early stages or is made only after surgical treatment for otitis media
Investigations
Pure tone audiogram
The main audiolologic feature of TB is the deafness out of proportion with the apparent degree of development of disease seen in the otoscopy. Generally it is moderate to severe hearing loss. It can be conductive, senserioneural or mixed hearing loss.
CT Imaging
Recent studies have shown that CT is the best modality available for the diagnosis of tuberculous mastoiditis; shows evidence of bone necrosis.
PPD Test
Not very conclusive
Bacteriological and histopathological studies
The diagnosis of tuberculosis otitis media is based on demonstration of acid fast bacilli within granuloma in biopsy materials, with or without the culture of mycobacterium tuberculosis from the biopsy, aural discharge or aspirate of the middle ear. Histology of tissues reveals granulations with epitheloid cells and multinucleated giant cells (Langhans giant cells), areas of central necrosis, lymphocytic infiltration, ulceration and signs of bone resorption.
Drug Therapy
Drug Therapy: It includes 4 drug regimen (Isoniazid, Rifampicin, Pyrizinamide and Ethambutol). Currently, the resistance to antitubercular drugs is a major problem and one of the main factors of difficulty in combating the disease.
Surgical treatment
Modified Radical Mastoidectomy if any of the following complications develop: facial paralysis, subperiosteal abscess, labyrinthitis, mastoid tenderness and headache . Surgery may be required in some cases to remove sequestra and improve drainage. When surgery is combined with adequate chemotherapy, there is a good chance of healing with a dry ear with a good prognosis. Recently, the role of surgery has been revised. In the past, it was done to provide drainage, to control spread to central nervous system and to relieve facial paralysis. The advent of specific chemotherapy has challenged all this, and today surgery should be reserved for decompression of the facial nerve and for removal of necrotic material which might provide a nidus for the organism to remain out of reach of anti tuberculous therapy. Sometimes, demonstration of sequestra in temporal bone during surgery will give a clue to diagnosis.
(40 year old Madhuri had discharging ears as long as she can remember. She never had a dry near. She lost her hearing about 80 percent. She had Pulmonary TB at the age of 4 or 5 and was treated. Now TB of the middle ear and Mastoid is suspected, and the polyps from the ear are sent for Histopathology. Mastoidectomy and Tympanoplasty is done in Jubilee Hospital, Trivandrum, South India).
